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National Review of Nursing Education

Midwifery Education

Literature Review and Additional Material (Revised Edition)

Appendix F

Evidence-Based Midwifery Practice:

A Strategy to Teach Midwifery Students about Woman Centred Care in Australia

 Nicky Leap and Caroline Homer ¹

Division of Women’s and Children’s Health, St George Hospital Sydney, and the Faculty of Nursing, Midwifery and Health, University of Technology Sydney.

Introduction

This paper describes the development of an subject that incorporates woman-centred principles into an evidence-based approach to midwifery practice. In particular, the rationale and strategies associated with developing and teaching one subject in the program, ‘Evidence-Based Midwifery Practice’, will be described. The paper will describe how the subject was designed using a definition of ‘woman-centred care’ and the ‘Five Steps of Evidence-Based Midwifery’ (Page 2000) as a framework. This framework also encouraged us to design assessments that would enable students to look beyond developing the skills of critiquing research findings to explore how they might discuss evidence with individual women and how they might effect change in the workplace through the development of evidence-based protocols/guidelines for practice.

The first time that we taught the subject ‘Evidence-Based Midwifery Practice’ the group consisted of 18 students. Apart from one qualified midwife, these students were nearing the end of their midwifery training and in order to complete the pre-revised version of the Graduate Diploma, they had to undertake a research subject. In their evaluation forms the students reinforced our decision to offer the subject at the beginning of the program in the future:

We have recently finished teaching the subject to a group of 48 students. All these students are at the beginning of their midwifery education program for entry to the profession and have just started their one-year placement as employed student midwives in Sydney maternity units. We built on the program we taught the first group. This involves considering the students’ written and verbal evaluations, our appraisal of their assessments and our on-going reflections on what appears to work/not work in terms of enabling students to define appropriate evidence in relation to individual women’s experience of childbirth.

Defining ‘evidence-based practice’ and ‘woman-centred practice

An important first step in teaching the subject, ‘Evidence-Based Midwifery Practice’ was to define ‘evidence based practice’ and ‘woman-centred practice’ for the students by explaining terminology, concepts and the history of the evidence-based practice movement and how this has affected maternity care. Inevitably this involves discussion about the politics and challenges that surround the subject as well as a basic explanation of different quantitative and qualitative research methods and how these are rated in terms of reliable evidence.

Evidence-based practice is a term widely used to describe the process of informing practice by evidence from research. According to Gray (1997), values and resources also play a role in any decision-making process. He describes evidence-based clinical practice as ‘the judicious use of the best evidence available so that the clinician and the patient arrive at the best decision, taking into account the needs and values of the individual patient (Gray 1997 p.213).

The evidence based practice movement defines a hierarchy of research methods suitable for addressing clinical questions. At the top of the hierarchy is the quantitative, randomised controlled trial’ (RCT) known as the ‘gold standard’. In accepting the RCT as the ideal evidence for positive intervention, Oakley (1992) identifies its poor applicability to topics of sociological inquiry and lists the opposing characteristics associated with research methods and their epistemologies: the social, qualitative, hard-to-measure compared to the biological, quantitative, easy-to measure. For some time, midwives have expressed concern about the poor status of qualitative research in the evidence-based practice movement and the inappropriate use of randomised controlled trials in situations involving women’s choice and the potential disturbance of physiological processes (McNabb 1989; Walsh 2000). It is suggested that even where researchers share the philosophy of woman-centred midwifery practice, the application is undermined by quantitative methods (Walsh 2000). Even Murray Enkin, the acknowledged ‘Godfather’ of evidence based maternity care has been heard to say, "The things that count cannot be counted" (personal anecdote, ACE Tour, 1995).

Walsh (2001) suggests a widening of understanding of what constitutes ‘evidence’. Walsh suggests that an improved awareness of power relationships, stereotyping and dominant biomedical ethos that exists within maternity units will help individuals to see more clearly how they might overcome obstacles to implementing evidence-based midwifery practice.

In recent years, the straight forward sounding process of evidence-based decision making has been challenged further in light of the relatively limited occasions where there is clear cut research-based evidence to inform decisions (Sackett et al. 2000). There is a growing body of opinion arguing that authoritative knowledge should therefore not be discounted in the drive to develop evidence-based practice, particularly around decision-making regarding individualised care (Sackett et al 2000).

In light of such debates, our challenge was to find a way to teach Evidence-Based Midwifery Practice that also incorporates the midwifery principles of being ‘with woman’, thus enabling practice where women are central to the process of evidence-based decision-making. Clearly, alongside definitions of ‘evidence-based practice’, there was a need to discuss what is meant by ‘woman-centred practice’ with the students in order to explore these issues fully. Although the phrase is referred to liberally in midwifery discourse, there is little to be found in the literature that defines succinctly what is meant by ‘woman-centred’ midwifery practice. We decided to use the definition written for the Nurses Registration Board of New South Wales (Leap 2000) as a starting point for discussion:

In midwifery practice, ‘Woman Centred Care’ is a concept that implies the following:

• Midwifery care is focused on the woman’s individual, unique needs, expectations and aspirations, as opposed to the needs of the institutions or professions involved.

• Midwifery care recognises the woman’s right to self-determination in terms of choice, control and continuity of care from a known or known care-givers.

• Implicit is the notion that woman centred care encompasses the needs of the fetus/baby, the woman’s family, her significant others and community, as identified and negotiated by the woman herself.

• Midwifery care follows the woman across the interface between institutions and the community, through all phases of pregnancy, birth and the postnatal period. It therefore involves collaboration with other health professionals when necessary.

• Midwifery care is ‘holistic’ in terms of addressing the woman’s social, emotional, physical, psychological, spiritual and cultural needs and expectations.

Relating this definition to evidence-based midwifery practice provoked heated discussion in both groups of students. Topics raised included organisational culture in maternity care, the role and responsibility of the midwife as a practitioner in her own right, and the shift of loyalty from the institution to the woman that occurs when midwives provide continuity of care (Brodie 1996). In facilitating these discussions, we were able to link them to an exploration of the history and development of evidence-based practice in maternity care and both the actual and potential role of midwives within that movement.

The development of an ‘evidence based practice’ approach in maternity care

Folklore has it that in order to tell the story of the development of evidence-based practice in maternity care, one has to start with the presentation of ‘the wooden spoon award’ to obstetrics by Archie Cochrane in his book Effectiveness and Efficiency: Random Reflections on Health Services (Cochrane 1972). Cochrane identified obstetricians as the worst offenders in a situation where decision-making was based on opinion, untested extrapolation, tradition, assumption and precedent, rather than reliable research findings.

As a result of the ‘wooden-spoon award’, certain obstetricians around the world began to assemble a register of controlled trials in perinatal medicine. A team led by Ian Chalmers of the Oxford Perinatal Epidemiology Unit, including midwives and childbirth activists and contacted over 40,000 obstetricians and paediatricians in 18 countries. They searched medical databases, and over 60 key journals in their quest to identify studies likely to provide the best evidence for evaluating maternity care. They then developed a systematic method of synthesising all the data and commenting on the implications for practice of the findings using accessible language. The result was a seminal, two-volume, 1500 page book entitled Effective Care in Pregnancy and Childbirth (Chalmers et al. 1989). Known affectionately as "Easy-Peesy" (ECPC), this text led to a revolution in maternity care. For the first time, maternity care providers had a resource, based on systematic reviews of reliable research findings, that they could use in the process of helping individual women make informed choices about their care. This was such a significant shift in what was possible that those who were practising at the time have been known to compare the question, "Where were you when you… first heard about ECPC", to the oft-quoted question regarding the death of JFK (personal anecdotal evidence).

ECPC gave rise to an electronic database that now includes data relating to all aspects of health care. Updated quarterly, The Cochrane Library is named after Archie Cochrane. A Guide to Effective Care in Pregnancy and Childbirth was published in order to make the findings accessible in a more portable format (Enkin et al. 2000). Referred to in midwifery circles as "The Bible", it continues to be reprinted regularly, reflecting updated versions of The Cochrane Library. The basic categories designed by Ian Chalmers and colleagues in ECPC continue to form the basis of the conclusions of systematic reviews of research findings relating to childbirth:

• forms of care that reduce negative outcomes of pregnancy and childbirth

• forms of care that appear promising but require further evaluation

• forms of care with unknown effects, which require further evaluation

• forms of care that should be abandoned in the light of the available evidence

In 1985, a group of midwives in the UK responded to the identified need to develop evidence-based practice by developing the ‘Midwives Information and Resource Service’ (MIDIRS). This organisation continues to publish the MIDIRS Digest, a quarterly journal containing reprints of relevant articles from over 500 journals as well as operating a topic-based searching service for midwives. An important tool to aid midwives in giving information to women and discussing the implications of research when making decisions is the series of MIDIRS Informed Choice Leaflets (MIDIRS 1999). These leaflets are peer reviewed and come in two versions: one for professionals and one written in ‘plain English’ (reading age 12), for women. The leaflets address common topics (such as ‘Ultrasound in Pregnancy’, ‘Positions in Labour’, and ‘Fetal Heart Rate Monitoring in Labour’) and the professionals’ leaflets list the sources of evidence. The leaflets are a valuable resource for women and midwives. In particular, they have relevance for the assessment in this subject which included talking to women about evidence in a ‘written role play’.

The Five Steps of Evidence Based Midwifery

In designing the ‘Evidence-Based Midwifery Practice subject, our major strategy to ensure that research is incorporated into practice and not seen as something ‘other’ was the use of the ‘Five Steps to Evidence-Based Midwifery’ proposed by Lesley Page (2000) in The New Midwifery: Science and Sensitivity in Practice. This framework dovetails with the woman-centred philosophy of midwifery programs offered at UTS and offers a clear pathway for integrating research into practice that involves women.

Page (2000, p.9) describes evidence-based midwifery as a process that involves finding and weighing up all the evidence in partnership with women so that they can make decisions about their care. She identifies that this process should include the personal integrity of the mother, baby and family, and that the emotions related to the experience of birth have profound long-term consequences for all involved. With this in mind, she proposes that five steps need to be taken to practise evidence-based midwifery:

The Five Steps of Evidence Based Midwifery are:

• finding our what is important to the woman and her family

• using information from the clinical examination

• seeking and assessing evidence to inform decisions

• talking it through

• reflecting on outcomes, feelings and consequences (Page 2000, p.10)

In developing the ‘Five Steps of Evidence Based Midwifery’, Page (2000) has drawn on the principles of ECPC (1989) and the identified needs of women outlined in the important British Government policy document, Changing Childbirth (Department of Health Expert Maternity Group 1993) to which she was a major contributor. She has also built on the work of Sackett et al (2000) and Gray (1997) who describe four sources of information including individual values and preferences, information from the clinical history and examination and from the best available evidence and the context of care.

Using the Five Steps of Evidence Based Midwifery

During the process of designing, teaching, evaluating, re-designing and teaching the subject ‘Evidence-Based Midwifery Practice’ with the two groups of midwifery students, it has become increasingly clear to us that the ‘Five Steps Framework’ offers an important teaching and learning strategy beyond our initial expectations. We have used this framework as an innovative way of expanding an understanding of what constitutes ‘evidence’ and of exploring how this might relate to individual women’s lives. In teaching the subject we realised that the Five Steps to Evidence-Based Midwifery framework could be used as a tool for ensuring that all teaching and learning in the curriculum is clearly situated in practice as it relates to individual women's experiences of childbirth.

The following comment by a student in her evaluation of the program confirms that, for her, this approach was useful:

Teaching and Learning Strategies

The teaching and learning strategies we employed maximised opportunities for participatory action and interaction.

We decided to adopt the standard feminist process of beginning each session with the students by facilitating a ‘round’ to enable the group to hear every individual speak (Eldridge Wheeler & Chinn 1991). The first round enabled us to learn each other’s names and places of employment and to hear from students in turn about their previous experience of studies related to research. This was useful to understand the levels of anxiety that they brought to the subject. It also highlighted the need for us to find ways to address de-mystification, reassurance and careful explanation throughout the program.

At the beginning of each subsequent session we asked the students to talk about any situation they had noticed since the last session where evidence was being used/not being used in practice. All the students were in employed practice in hospitals and they readily provided examples that provoked discussion. We were able to refer them to relevant literature on a wide variety of topics and role modelled looking things up in the Guide to Effective Care in Pregnancy and Childbirth whenever we ourselves were unclear about the best available evidence. This process:

• ensured that the students were looking out for ‘real life examples’ to bring to the next session;

• enabled the students to discuss conflicts between evidence and their experience;

• reinforced the importance of considering individual women’s circumstances;

• gave us a chance to explore many situations where there is no clear evidence;

• promoted discussions around notions such as ‘uncertainty’, and ‘challenging and changing practice’ and ‘power relationships’ in the workplace;

• stimulated awareness of different styles of practice in their placement areas; and,

• role modelled life-long learning principles of ‘looking things up’.

We were particularly keen to develop assessments that would stimulate students to relate the process of appraising evidence to 'real life' situations. The first assessment was designed as a group exercise in appraising research articles followed by an exercise in using this process to develop clinical protocols for a birthing unit. Examples of labour ward protocols were given to the students following a discussion about the potential of inter-disciplinary protocol development as a tool for changing culture. The Book of Readings for the subject contained a series of articles related to subjects concerning labour and birth. The subjects were: continuous electronic fetal monitoring; upright positions for labour and birth; spontaneous pre-labour rupture of membranes at term; and, spontaneous versus directed pushing in second stage.

The task was for each small group to choose one of these topics to consider in depth. Time was allocated in the classroom for them to appraise each of the relevant articles according to the clearly defined framework of appraisal questions under the headings of synopsis and credibility profile set out in Knowledge for health care practice: a guide for using research evidence (Brown 1999). We made sure that we were accessible to the students as a resource while they carried out this exercise by circulating in the classroom and engaging with them if invited to contribute or clarify the task. The students were told that they would be given a grade that would be the same for all members of the group, worth 60% of their final mark.

The second assessment was an individual assignment that built on the group process. Using the same set of articles and the protocol that they had developed, students were asked to write a written role-play:

• You are discussing the clinical issue in your protocol with a woman in the antenatal clinic. In the assignment you must:

• Describe the evidence relating to the clinical issue in language that she can understand.

• Answer the series of questions that she asks you (we will give you some of the questions) in relation to the evidence. Again, you may need to find additional papers but if you do you will need to appraise them for credibility.

Poor communication and information giving by midwives and the impact on women has been well described by Kirkham (1989) and Lavender et al (2000). Our intention in devising the written role-play was to give students a chance to think hard about how they enter into discussions with individual women about research evidence, in particular, taking into consideration power relationships and the use of language (Leap 1992). In order to help the students explore these issues before undertaking the assessment, we performed a series of verbal role-plays - conversations between a midwife and woman in the antenatal clinic - and invited the students to critique the interactions. We used examples of midwifery behaviours such as patronising, authoritarian, alarming, vague and dismissive interactions. After marking this assessment, we were convinced that the written role-play is a useful exercise. The students found it challenging and thought provoking. The written role-play highlighted marked variation in competence regarding communication skills and awareness of language and power and we were thus able to enter into a dialogue with individual students about these issues.

Conclusion

The subject ‘Evidence-Based Midwifery Practice seems to be an effective way to discuss research methods, the process of carrying out research, and the implications for practice, whilst at the same time informing the students about a wide range of important studies that will inform their midwifery practice. Thus this subject has become an integral part of the process of learning about midwifery practice as continued throughout the rest of the program. Ongoing evaluation will help develop this subject even further.

Foot Note:

1.Contact authors regarding references in this paper

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