evidence-informed midwifery 3:
evaluating midwifery evidence
sara wickham
This article was originally published in
Midwifery Today. Republished with permission.
The need to evaluate any form of evidence is clear: as midwives, we are trying to eradicate the kind of ritualistic and unevaluated practices which have dominated the care of childbearing women for the last few decades. The statement, “because I've always done it that way”, does not justify continuing a particular practice or intervention: we need to be sure that the care we offer is based on sound evidence.
The previous article explored in-depth the process of evaluating research evidence. Because so much work has been done into this area, and because research and the scientific model have held their place as the 'gold standard' in some circles for so long, there is a generally-accepted process through which we can evaluate the evidence that such work offers.
Evaluating other types of knowledge is less straightforward, and there are as yet no generally-accepted tools through which we can evaluate experiential evidence or the evidence which we glean from women's or our own intuitive processes. Yet these types of evidence are just as important as research, if not more so, in the decisions which women and midwives need to make together. Types of evidence such as the woman's philosophy or choice clearly do not need to be evaluated by midwives or other professionals; while we may seek to help women consider their feelings, philosophy and choices, we should not be setting out to judge these. However, evaluating the evidence we gain from experience or intuition can help us to determine whether our 'hunches' stand up to scrutiny, and can help provide useful information for other midwives. This article seeks to explore some of the ways in which we might evaluate forms of evidence other than research.
Knowing Yourself
Before using any of these tools, it is important for midwives to understand their own philosophy, because this has an impact on the way they see birth and the outcome of certain actions or decisions. Self-awareness may be the most important first step in this process for midwives. Some midwives are already aware of their philosophy and the origin of their beliefs; others may find this a helpful exercise to undertake. If you would like to explore this further, you may find the questions below helpful as a general guide to doing this.
Gathering Evidence from Experience
One of the tools which is used in midwifery education to enable students to explore their practice and thought processes is that of reflection. At its simplest, this is about asking yourself a whole range of questions about an issue or event, and trying to learn from the process. Often the questions lead to more questions, which enable a thorough analysis of the subject and cause you to 'pull it apart and see what it is made of'.
Reflective questioning can take place alone or in a group of people, and involves analysis of your feelings and hunches as well as evidence or knowledge from physiology and research. It is a process where a number of different forms of evidence can be 'thrown into the pot' in order to fit them together and learn from the process. Reflection can be used to evaluate any outcome you have experienced or decision you have made. It can also be used to evaluate knowledge which has derived from experience; by thinking through, writing about and discussing a particular situation, you can explore other possibilities, explanations or factors which might have affected the outcome.
Many midwives already use reflective processes when they have a less than optimal outcome. They seek out midwife friends or colleagues and discuss the case, in the hope that others can throw some light on what went wrong, why something happened, or what might have been done differently. But we also need to reflect upon events and situations which went well, in order to determine 'what works', and to increase our knowledge of experiential evidence. Setting up regular reflective sessions for groups of midwives (and some of the best I have been to are very informal and involve campfires and wine!) can be an excellent way of evaluating the decisions you have made and gathering evidence from your own experience and that of other midwives. It can be as simple as sharing and discussing birth stories, and trying to learn from these experiences. But often, much can be learned from the questions which ensue and many midwives follow up particular questions through the published literature and research, in order to develop their own practice and share their findings with others.
Physiological Evidence
Evidence from physiology is linked to the idea of evidence from 'common sense'. When you identify a 'new' piece of evidence, often the first question to ask is: does this make sense to you? When you explore the physiology of a particular aspect of birth, does it fit with the other information and evidence you have in the area? This is also where the issue of understanding your philosophy comes in: if you believe in the midwifery model of birth, you will be more likely to find and accept information which shows birth and other natural processes to be efficient and effective. Proponents of a pathological model of birth, on the other hand, will tend to look for pathology in situations where there may be none.
Because of the influence of our philosophy on the processes we use to evaluate evidence, this type of evidence may be best presented in the form of an 'argument'. If you think you have 'discovered' something from your experience which relates to the physiology of birth, can you pull the pieces of information together into a coherent argument? Once you have done this, you can offer it to colleagues and friends to see if they agree with your logic and thought patterns, if they can find flaws or loopholes in your reasoning, or if they can add anything to your debate.
In this case, it can also be helpful to talk to people who have a different philosophy from your own. I once
carried out a piece of research which challenged the necessity of an intervention which had previously been regarded as essential. While I received welcome support from many midwives who agreed with my findings and supported my work, one of the people who provided the most help to me was a medical colleague. Although a personal friend, he was initially sceptical about my work, and by finding the holes in my arguments was able to help me refine my thinking and knowledge about the subject. The process of working together on this also changed the way he thought about the subject, and helped us both to understand each others' point of view better.
Intuition and 'Hunches'
Intuition is, for me, one of the most fascinating aspects of midwifery decision-making. When I was a student midwife, a very experienced midwife who I was working with suddenly decided to go and visit a pregnant woman, without knowing exactly why. The woman was not due for a visit for another week. On arrival at her house, we discovered that she felt unwell. Her blood pressure was slightly raised but within normal limits. Nonetheless, the midwife (who was normally very reluctant to transport women) asked the woman to go to the hospital. Blood and other tests which were performed there showed that she had quite severe pre-eclampsia which would almost certainly have caused problems for her and her baby within the next few days. Afterwards, the only explanation the midwife could give for having gone to the woman's house was that she kept thinking about her and getting a sense that all was not well.
Laura Day, in 'Practical Intuition' suggests that we keep an 'intuitive notebook, to help us chart our progress and learning in this area. She reminds us that we are all intuitive, but that we often forget this and rely instead on logical or 'common-sense' thought processes. If you wish to evaluate your own use of intuition, a journal or notebook might be a good way of doing this: keep a record of what you feel, any images or symbols which come to you and then record the outcome or events which followed this. You may find that certain symbols are, for you, indicative of certain outcomes.
Laura describes a fun way of developing and evaluating your intuitive processes and demonstrating their effectiveness to others and calls this the '5-minute psychic hotline'. Each person in a group writes down a question which they would like answered, and puts this in a sealed envelope in a pile. You need to warn the group that the question will be shared within the group, in case it is very personal. Envelopes all need to be similar, so you can't tell which is which. The pile is then shuffled and each person in turn picks up an envelope and describes any feelings, images or thoughts which come to them.
Another group member records these and, when the person has finished speaking, the envelope is opened and the intuitive answer to the question is analysed. You may be surprised at the accuracy of the answers! If some people in the group really don't believe they are intuitive, tell them to make things up - the intuitive and subconscious mind knows what it thinks and feels, even if the conscious and logical part of the brain tries to over-ride this.
It is also important to help women trust their own intuition and body knowledge. Stories of women who 'knew what their body or baby needed' can be helpful in this case, and the game described above can be adapted for use in childbirth education groups. A simplified version can be made by putting the womens' or couples' names in envelopes and asking people whether their imagery and intuition suggests the baby will be a boy or a girl. They might also like to see if they can get an impression of the weight of the baby, or the time of the birth. Although the 'proof' is not available before the birth, it can lead into a discussion about intuition and certainly provides entertainment at the postpartum reunion!
As before, these are by no means the definitive ways of evaluating midwifery evidence, but they may provide starting points for those midwives who are interested in exploring the areas discussed. I would argue that, because midwives and women use these forms of evidence in making decisions about pregnancy and birth, we need to develop and utilise tools for their evaluation. This is not only about ensuring that practice is based on sound evidence (rather than ritual or habit), but it is also about being proactive in acknowledging, respecting and promoting the 'ways of knowing' which are used by women.
References:
Day, L (1996) Practical Intuition. Vermilion, London.
Exploring Your Philosophy of Midwifery
Answering the following 25 questions, either by thinking them through, writing your thoughts down, or discussing them with others can help you begin to understand your philosophy and feelings about birth and midwifery. One of the most effective ways of doing this is to get a friend or colleague to use the questions to 'interview' you. She can add other questions in areas which appear relevant to you. You can ask her to write notes or tape the 'interview' in order to look back over what you have said afterwards.
1. What are your beliefs about life in general?
2. What were your childhood experiences with pregnancy and birth?
3. Did you attend any births before becoming a midwife?
4. If so, how did they affect you?
5. What did you feel about birth before you became a midwife?
6. Why did you become a midwife?
7. How did / do you feel about your midwifery training?
8. How has your practice changed since you became a midwife?
9. What are your fundamental beliefs about birth?
10. Can you identify where these beliefs come from?
11. What do you feel women need from their midwife?
12. What do you feel women can expect from their midwife?
13. What did you feel about your own birth experiences (if relevant)?
14. What do you think are the essential qualities of a midwife?
15. What kind of midwife do you want to be?
16. What are the most difficult 'ethical issues' in practice for you?
17. Why are they an issue?
18. What can / do you offer childbearing women?
19. If you could tell all childbearing women one thing, what would it be?
20. What do you find difficult about being a midwife?
21. What are your goals?
22. What would you like your midwifery colleagues to remember you for?
23. What do you feel strongly about?
24. Who do you admire in the 'birth world' and why?
25. What is the one 'birth question' that you would really like answered?