Using Evidence-Based Care to Improve Women's Health in Childbirth


Like many of you, I keep a number of interesting things affixed to my office door for all to see. These items include photos, postcards, maps, artwork, slogans, and announcements, and these are periodically removed and updated. One item has been there a long time, maybe 4 years now. It is a bumper sticker with this message: “SURPRISE! Midwifery is the evidence-based model of maternity care!” I have not removed it, because this statement is not meant to be provocative; it is not a joke. It is actually the truth, and this is a good time for the profession as a whole to embrace it and use it to the benefit of women's health.

Last year, while I was on sabbatical in Melbourne, Australia, Tekoa King sent me the citation of an article to read and ponder. The article presented the results of an interview study conducted with two large groups of experienced Certified Nurse-Midwives (CNMs) in the United States in 2001 and 2002.1 The authors wanted to assess CNMs' understanding of evidence-based care and find out whether CNMs used the ‘evidence’ argument to advance the midwifery model of care when disagreements arose with standard medical protocols. This research found that the CNMs interviewed had an incomplete understanding of evidence-based care, and did not always use it to argue for midwifery principles, even though the midwifery model is very well supported by all available research evidence. It is not known if these findings are an accurate reflection of the majority of midwifery practices in the United States. However, the possibility that midwives may be missing an opportunity to promote the midwifery model of care and, in doing so, improve the health of childbearing women, is disconcerting.

Midwives are experts in normal childbearing2 and should be the ideal caregivers to help protect and preserve normalcy and health. Authoritative sources, such as A Guide to Effective Care in Pregnancy and Childbirth3 and the World Health Organization's Principles of Perinatal Care4 have rigorously evaluated the available evidence on numerous aspects of childbirth care. The evidence from this body of research and the resulting principles of care are mirrored in our own core competencies and hallmarks of midwifery: 1) pregnancy as a normal process; 2) nonintervention where complications are absent; 3) involving women in all decisions about their care; 4) support for choices and options in care for women; 5) appropriate use of technology; 6) provision of support and human presence; 7) breastfeeding support and assistance; and 8) care with cultural sensitivity.5 These are things that midwives already know, value, and practice.

There are several reasons why all of this matters to clinicians in practice. First of all, childbirth is a very common clinical condition. It is the most frequent reason for hospitalization in the United States.6 Most births occur to healthy women, who with preparation, information, and support, should be able to accomplish normal vaginal birth in most cases. Because so many people are affected (and so much money is involved), health promotion in pregnancy and childbirth should, if we plan health care services logically, be a high priority for the nation—and midwives are the experts here. Midwives have something to say, a lot to teach, and can serve as models for other professionals about normal childbirth.

But a data disconnect has created a huge gulf. The care that today's childbearing women are getting, on average, is not evidence-based, and ample data clearly demonstrate that invasive technologies and surgery are over-utilized.7 Care is not individualized. In many settings, it has become narrowed down to a short list of choices and options. While this may make things work more smoothly for hospitals and professionals, it negates the needs and wishes of individual women and their families. It also increases the likelihood of adverse health effects secondary to use of procedures and technologies that were not truly necessary in the first place.

Incorporating current evidence into practice would improve the health outcomes of today's childbearing women, and thus, this issue of the Journal of Midwifery & Women's Health was created. In this issue, readers will find current and readable reviews of evidence for practice on a variety of important intrapartum topics: management of the latent phase,8 and first and second stages of labor9–10; management of the perineum11; intrauterine fetal resuscitation12; breastfeeding initiation13; fetal to newborn transition14; planned home birth15; management of prelabor rupture of membranes,16 and others. Our intent is that this mini-library of updated and distilled information will be useful to busy clinicians, and that clinicians will share this information with their practice colleagues and with their clients.

The best analogy for the current system of childbirth care in this country is in my mind, a runaway train. The brakes need to be applied. Midwives are in a position to set a change in motion: by applying evidence in practice, by modeling it, by teaching and sharing it with other health care professionals, and by pressing the case that all women deserve evidence-based care. Turning things around happens one birth at a time.