evidence-informed midwifery 1:
what is evidence-informed midwifery?
sara wickham
This article was originally published in
Midwifery Today. Republished with permission.
This is the first of a series of articles which looks at the topic of evidence-informed midwifery and the various questions this raises for midwives. Evidence-informed practice is fast becoming the accepted 'standard' in many fields of health care, including midwifery, and midwives are ideally placed to inform this debate and ensure that the unique knowledge we have is both protected and validated for future generations. This first article will look at the concept and scope of evidence-informed midwifery and consider some of the issues currently being debated in this field.
Defining evidence-informed midwifery
The original term 'evidence-based midwifery' was partly derived from the concept of 'evidence-based medicine', which David Sackett et al (1996) define as, “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”. However, I would argue that evidence-informed midwifery is actually very different from what is generally understood by evidence-based medicine.
The first question we have to ask is what we mean by the term 'evidence'. Ther term 'evidence-informed midwifery' is not synonymous with the term 'research-based midwifery', although this has previously been used in some contexts. One of the major criticisms of the concept of evidence-informed practice is that it is seen as reductionist, positivistic and based in the medical scientific paradigm. As Lesley Page (1996) notes, this does not have to be the case. Indeed, she shows that there are as many different forms of evidence as our understanding of midwifery and women will allow us to see. Some of these are listed below.
There is also an important distinction between the words 'based' and 'informed' - the latter is preferred by those who realise that midwifery is a process which is about far more than evidence. Midwifery is certainly informed by evidence (whether we personally like the concept of evidence-informed midwifery or not!), but many would argue that it is not based on this alone.
What Constitutes Evidence?
Woman's choice / philosophy * Intuition (woman / midwife)
Women's experience * Research
Midwifery experience * Body knowledge
Life experience * Physiology
Insight * Philosophy
Common-sense reasoning * Policy and practice
One of the main differences between evidence-informed midwifery and evidence-based medicine is that definitions of evidence-based medicine still accept science as the dominant meta-narrative, as can be seen by Walshe et al's (1995) definition of evidence-based medicine; “Moving away from decisions based on opinion, past practice and precedent towards making more use of science, research and evidence to guide decision-making.”
This is exactly the kind of definition which has been rejected by some midwives, who understand that past practice and precedent can, if used appropriately, be useful tools in informing practice decisions. The key is to ensure that experience - as with all forms of evidence - is used appropriately. While it is never justifiable to practice in a certain way because “I have always practiced that way”, learning from experience is a useful and neglected form of evidence in mainstream health care practice.
Another reason for moving away from a total reliance on the scientific paradigm is that it is estimated that only about 12% of midwifery and birth decisions can be based on research evidence (Page 1996). While science will continue to be useful in its own way, it will never give us all the answers, and there are clearly many gaps in the evidence it is able to offer, which need to be filled through other sources of knowledge. Evidence-informed midwifery practice is not a recipe book, where there is one solution for every question. Each question, being asked by an individual women, is unique and informed by a variety of evidence.
So what is the point of all this? I feel there are three main issues which can be addressed through the use of evidence-informed midwifery. The first of these is concerned with the fact that midwives support women making decisions. And women come to midwives because they need expert knowledge on which to base these decisions. The more we can generate for ourselves in the way of knowledge and understanding of women's bodies, the more we can help those women and their babies to make the decisions which are right for them.
Secondly, we are in danger of losing those forms of evidence and ways of knowing which are unique to women, and which may be the most relevant to the ways we work together. While some of the ideas we have may not be mainstream at present, embracing and utilising the concept of evidence-informed midwifery may be one way in which we can make them so. The question of how we can validate midwifery knowledge is one of the most exciting 'hot topics' right now, and will be the subject of a future article in this series.
The third reason is a more personal one. Having worked with midwifery research for a number of years, I am aware that analysis of this research points to the very things that we do know in our hearts; that birth is a sacrament which is 'as safe as life gets'. Yet we live in a society where women are taught to distrust their bodies and the process of birth, turning instead to doctors and technology. We need to enable women to understand that, for the majority of people, even scienctific research shows that home birth and midwifery are safer than the alternatives. For me, promoting evidence-informed practice is a way to ensure that more women and babies get safe, effective, loving midwifery care which empowers them as people and parents.
The whole area of evidence-informed midwifery raises far more questions than answers at present. Having established that we may need to be more inclusive of what we define as 'evidence', we need to address the issue of validity - how do we, as individual midwives, evaluate any particular form of evidence? The process that we use to evaluate research is well-understood (and the subject of another article in this issue). But how do we ensure that we are using our experiential knowledge appropriately? How can we justify using intuitive ways of knowing - not even necessarily for ourselves, or for the women we work with, but for women who have learned not to trust their feelings or for other practitioners who may choose to incorporate this into their practice?
As midwives, we need to decide whether we wish to embrace this concept and pursue the goal of expanding the midwifery body of knowledge. Should evidence-informed practice be a goal for all midwives? How can we best use this to promote the midwifery model of care? And how can we use evidence-informed midwifery to make positive changes in birth and ensure that the care of all women is informed by the best possible evidence? I would suggest that evidence-informed midwifery is here to stay, whether we like it or not! And that we can choose to inform the direction that it takes, ensure that women's and midwives' knowledge is validated and use it as a positive model of care for women and babies.
References
Page L (1996)
The backlash against evidence-based care
Birth; 23 (4) pp 191-192.
Sackett D, Rosenburg W, Grey J et al (1996)
Evidence-based medicine: what it is and what it isn't
BMJ, No 312, 13 January 1996.
Walshe K (1995)
Given in evidence
Health Service Journal; 29 June 1995