Evidence based midwifery practice Sarah Stewart

sarahstewart07@gmail.com

http://sarah-stewart.blogspot.com

http://www.youtube.com/watch?v=OeA_OKqqBJ4

Why EBM?

How would you define EBP?

• Identify key words –

word cloud

• http://www.wordle.net

Definition

• It is about using research rather than doing it.

• It is a movement away from always doing things in the way in which we were taught and from decisions based on personal opinion.

• It requires that we look for and appraise research evidence to inform decisions about tests, treatments, patterns of practice, and policy (Page, 2000).

Why use evidence?

Image: 'Savage walk: don9t ask, just go' www.flickr.com/photos/61787893@N00/275371357

Ritual, habit and routine

Image: 'through the tollbooth.... again' www.flickr.com/photos/44124472651@N01/345154087

EVIDENCE vs RITUAL HABIT ROUTINE

Image: 'Dusting for prints.' www.flickr.com/photos/36521968006@N01/246535658

• In pairs think about your own midwifery practice. Are there any practices and/or interventions that are being carried out during the childbearing phase despite you knowing that they are not based on evidence? Can you list some?

• Now think about why the practice or intervention has not changed.

Asking and Formulating Answerable Questions

• What’s got four legs, one wheel and flies

• A dead sheep in a wheelbarrow

PICOT FRAMEWORK (Jackson, 2006)

• Five parts to well-built clinical questions:– Participants (client group/problem)– Intervention– Comparison (there is always an alternative)– Outcome– Timeframe Image: 'picot socks'

www.flickr.com/photos/60576152@N00/419127278

Example of a Formulated PICOT Question

• In a woman with a normal pregnancy and severe cramps in her leg at night, is extra calcium likely to help, and are there likely to be any

side-effects

from the extra

calcium?Image: 'who are you?' www.flickr.com/photos/60012221@N00/107729240

The question can be broken down into PICOT:-

• Participants = woman with normal pregnancy

• Intervention = is calcium likely to help?

• Comparison = compared with exercise only

• Outcome = the reduction of leg cramps

• Timeframe = during pregnancy

Formulating a Question

• Use the PICOT Framework to write a question to guide your search for evidence.

• In pairs, formulate a question using the following scenario.

Clinical Scenario

• Ms Wax is approaching term. She has prepared a birth plan indicating that she wishes to avoid intervention in labour. At her 39 weeks visit, the fundal height is 39 cm, the fetus is active, her blood pressure is 120/85, and there is no protein in the urine. At this visit, Ms Wax wonders whether it is enough to listen to the fetal heart regularly or whether she should think about having continuous electronic monitoring.

• Participants– How would I describe a group of

clients/women like mine?

• Intervention– Which main intervention am I

considering?

• Comparison– What is the main alternative to compare

with the intervention?

• Outcome– What does this intervention effect?

• Time

Levels of evidence• What do you think this means?

• What types of evidence are there?

http://pixton.com/comic/idp0q5kr

Professional consensus• Guidelines from expert groups

• Paradox that EBP increases our uncertainty

• How would you define an expert?

Image: 'Trust us, we9re expert' www.flickr.com/photos/35034348187@N01/35555985

Guidelines

http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?guidelineCatID=26&guidelineID=74

Barriers to implementing EBM

Image: 'Thames Barrier' www.flickr.com/photos/16377475@N00/64248038

Strategies for developing ‘best practice’

Image: 'No retreat, no surrender' www.flickr.com/photos/16189905@N00/309451530

EBP and midwifery professionalism

Image: '6lbs 9oz' www.flickr.com/photos/44124365893@N01/91692347

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials Gordon & Pell, 2004.

References• GRADE Working group. (2004). Grading quality of evidence and

strength of recommendations. BMJ, 328, 1490- 1494.• Hamer, S. (1999). Evidence-based practice. In S. Hamer & G.

Collinson. (Eds.). Achieving evidence based practice (pp3-12). London: Harcourt.

• Jackson, R., Ameratunga S., Broad, J., Connor, J., Lethaby, A. & Robb, G. (2006). The GATE frame: critical appraisal with pictures. Evidence Based Medicine, 11, 35-38

• Munro, J. & Spiby, H. (2000). Guidelines for midwifery-led care in labour. Retrieved 22rd November, 2008, from http://www.aamatronas.org/vidocs/protocoloshefield.pdf

• Page, L. (2000). Using evidence to inform practice. In L. Page (Ed.). The New Midwifery: Science and sensitivity (45- 70). Edinburgh: Churchill Livingstone.

• SIGN. (2000). Grading system for recommendations in evidence based clinical guidelines. Scotland: SIGN.

• Spiby, H. & Munro, J. (2001). Evidence into practice for midwifery-led care. British Journal of Midwifery, 9, (9), 550-552.