Some decades ago, when the late Archie Cochrane, M.D. (for whom the Cochrane Database of Systematic Reviews is named) gave the entire field of obstetrics his famous “wooden spoon award,” he was in effect doing two separate but equally subtle things.
First, he was asking all of us caregivers to sharpen our definition of what “evidence” is. He was asking us to give more weight to certain kinds of evidence (notably results from randomized controlled trials) over other kinds. He was asking us to clarify our definition of the kinds of evidence that most matter to us. Second, he was asking us to take that special kind of evidence seriously and to allow it to be the greatest influence on how we care for our clients.
The articles in this series of the Journal of Midwifery & Women's Health demonstrate that both activities create both new opportunities and new responsibilities for certified nurse-midwives (CNMs) and certified midwives (CMs).
Thus, when the authors of several articles in this issue decided to value the evidence from randomized controlled trials and other high-quality research over other kinds of evidence, they were also deciding to allow that evidence to genuinely affect how they think about clinical practices. Sometimes, that may mean recognizing that the ‘conservative’ management approach (i.e. the general midwifery philosophy of conserving the woman in a normal, healthy state) does not necessarily preclude intervention of any kind. Examples of some insights that might be gained through the evidence presented in this home study program (HSP) follow.
First, Brucker (1) articulates that there is now a fairly large body of evidence showing that active management of women in the third stage of labor leads to less bleeding, at least for women birthing in hospitals. For me, that implies that CNMs and CMs may need to acknowledge that no intervention during the third stage of labor is not necessarily the best practice. It is our professional responsibility to weigh this evidence against our midwifery philosophy of birth as normal and decide which women are most likely to be harmed by a non-interventive approach. Evidence-based care allows midwives the opportunity to clarify what we mean by “best care” and by “conservative management;” if we take the responsibility to really let the highest-quality evidence be the most important influence on our clinical practice.
Second, Walker et al (2) takes the evidence on continuous electronic fetal monitoring to the next step by asking why a practice that is not based on the best evidence continues. Their data show nurses were supportive of intermittent auscultation, but many did not feel empowered to directly advocate for a change back to this traditional midwifery (and obstetric) practice. If midwives are truly advocates for women, then we are responsible for assuring the “best care” is incorporated into clinical practice. This means engaging our physician and nursing colleagues in evidence-based discussions, being open to students who bring new evidence into our clinical practices, and working both within the system and outside of the system with consumers to change practices to conform with best practice.
The opportunity to educate women about the real evidence for various interventions creates a responsibility for midwives to be able to synthesize and present the documented information in a form that can be readily understood by both clients and consumers, usually in settings where time is at a premium. This challenges us not only to be current in our knowledge, but also to be honest in our personal biases. For example, Updegrove's article (3) on circumcision presents strong evidence that circumcised males have less urinary tract infections in the first year of life. Will this information, along with the reported incidence and morbidity of these infections, be incorporated into our discussion about circumcision with childbearing families, allowing them to make a truly educated informed choice?
An evidence-based approach does not allow us to pick and choose evidence selectively to support our traditional way of doing things. If we do not honestly assess all of the evidence and acknowledge the places where there is no good evidence one way or another, then we cannot confront our colleagues who are doing the same to support their points of view.
The days are past when giving out “wooden spoon awards” is an effective way to prod a reluctant medical community. Indeed, an evidence-based approach to clinical practice provides opportunities for midwives to understand more clearly how to improve care, makes them responsible for studying the highest-quality kinds of evidence with special seriousness, and transfers accountability to them for applying the undisputed evidence to real-life clinical settings.