BIRTH 23:4 December 1996

GUEST EDITORIAL

191

The Backlash Against Evidence-Based Care

For those of us who practised in the dark ages of maternity care of the 1970s and 1980s, particularly in North America, the publication of Effective Care in Pregizancy and Childbirth (I) shone like a very bright light at the end of the tunnel. These were the days of routine purging with enemas in labor, sterilization of the pubic area, shaving, and episiotomy rates of over 90 percent. Images of women, shaved, draped in sterile green, flat on their backs, hands manacled to the table so they would not unsterilize the area or reach out to take their newborn into their arms, with fetal monitors and intrauterine pressure catheters in place are with me still. All these invasive, highly uncomfortable, and harmful procedures were introduced into routine prac- tice without benefit of evaluation, on the basis of un- tested theories.

Britain withstood the worst excesses of this techno- cratic, surgical birth, but even so, the legacy of the wholesale introduction of unevaluated treatments is still with us. For example, it is estimated that around 80 percent of women in Britain still undergo routine electronic fetal monitoring, the same rate as that in the United States in 1994, where it rose for the fifth consecutive year (2). EfSective Care in Pregnancy and Childbirth (1) was the voice of reason, providing a powerful tool to argue against treatments that were harmful, or may not be effective, and to argue for treatments that might be of benefit. It also put into widespread circulation the idea that we should not blithely assume treatments to be of benefit, or that care need not be evaluated. The Oxford Database of Perinatal Trials ( 3 ) and the Cochrane Pregnancy and Childbirth Database (4) followed, making the mater- nity services the first health care specialty to have a comprehensive review of evidence to aid practitioners (doctors, midwives, and obstetric nurses) in making clinical decisions, and in giving well-founded advice to women and their families. There was resistance and apathy, and even now some are unaware of the aids available to help practitioners access the latest synthe- sis of evidence. Important changes in practice, and in

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@I996 Blackwell Science, Inc.

the attitudes of clinicians and health service leaders and managers, have occurred, however, as a result of this work.

Now we are beginning to see a backlash against the whole idea of an evidence-based medicine, as this government-backed strategy is called. This backlash, from different factions, ranging from the clinical free- dom fighters who feel it is their inalienable right to make decisions about the care of mothers, babies, and families without recourse to up-to-date information, to the intellectuals who see “evidence-based medicine” as second-rate science passing on fourth-hand conclu- sions (5), to the midwives moving into higher educa- tion who confuse anything with the word “science” or “evidence” in the title with the medical model, and who avoid like the plague anything that might seem “reductionist.”

In part these reactions are natural and healthy. A danger exists in anything that is treated as an orthodoxy and that rules out individual thought and judgment. Unfortunately, the application of evidence-based care has been treated like this by some, who see it as a recipe for making decisions easily, or who believe that the only source of information in making decisions is hard evidence. This was never meant to be the case. Sackett (6) and others clearly describe the importance of information from the clinical examination and the patient’s values being brought together with the evi- dence to make clinical decisions.

Evidence-based medicine is also feared by some as a government plot to ration health care. It is true that the evaluation of treatments was proposed by Archie Cochrane (7) in an attempt not only to assess whether or not treatments or care worked, but also to establish whether or not they gave value for money. This was not with a view to rationing health care, but to ensuring the equitable provision of care. The fear of evidence- based medicine being used for excessive rationing is justified if it is left in the hands of any government that might allow cost constraint to be a driving force in the health service. Yet the proper and equitable use of resources should be of concern to any responsible professional who is making decisions about treatment and care. If professionals, who are likely to have the

192 BIRTH 23:4 December 1996

interests of those in their care uppermost, get involved in decisions about cost and effectiveness, it is more likely that these decisions will be made with a view to quality as well as cost. Left in the hands of the accountants and business managers, cost considera- tions will drive the provision of care.

If evidence-based care is to work in practice, it will depend on the provision of synthesized and evaluated evidence through organizations such as the Cochrane Collaboration, an international network. It is impracti- cal for any clinician to seek to retrieve and critique every piece of information. There is simply too much information available, and there would not be time to do it. In addition, few clinicians have the retrieval and critical skills demanded for such work. Such an approach requires some trust of those undertaking re- views of the evidence.

The interpretation of scientific evaluation is com- plex sometimes, even apparently well-conducted stud- ies may contain flaws (8), and interpretations of the findings may differ from one person to another. It is right, therefore, that clinicians, like scientists, should retain a degree of scepticism, and not always swallow the overview of evidence as an easy option. Predi- gested evidence can become a powerful form of control over care, and if exercised unwisely might become as bad as the authority or dogma of personal opinion.

Evidence-based medicine is part of a dramatic shift in thinking and approach. It requires new habits, skills, and abilities. Not every decision we make can or should be based on evidence; for one thing, a good estimate is that only about 12 percent of our clinical or manage- ment decisions can be informed by sound evidence, and for the rest the evidence simply is not available. Attempting to base our practice on evidence is not easy. It requires that we weigh up a number of factors in making decisions, that we base the information we give to families on a solid foundation of evidence, and that we find efficient ways of seeking and critiquing evidence so that the information we use is as unbiased as possible. It requires new habits of thought and prac- tice. It may cause us to question some of our more cherished beliefs, and shifts authority from practitioner to patient in a way that can be difficult to get used to. The application of evidence in practice, if done well, can be extremely uncomfortable!

Yet the shift to evidence-based care signifies and supports principles that may, if approached with com-

mon sense and kept in perspective, take us out of the dark ages and into the age of enlightenment. After all, is it too much to ask that women and their families, at this most critical time of their lives, should be offered care and treatments that have been evaluated, that we know might be of benefit? Is it too much to ask that we should be honest where uncertainties exist, or when we are basing decisions on opinion rather than evi- dence?

Like any good health care practice, evidence-based maternity care requires thoughtful attention to the indi- vidual woman and her family, keeping their individual concerns, values, and clinical needs uppermost. It re- quires an intelligent appraisal of the evidence, whether it is predigested or otherwise. Such an approach is likely to avoid harm, to ensure that we are not wasting time (both ours and the woman’s) or resources, and to give women and families the care that meets their individual needs and desires. This is not recipe-based care but a recipe for a healthy and happy start to family life.

Lesley Page, MSc, RM, RN (Canada) The Queen Charlotte’s

Professor of Midwifery Practice Thames Valley University

32-38 Uxbridge Road Ealing, London, W5 2BS

United Kingdom

References

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5. 6.

I.

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Chalmers I, Enkin M, Keirse MJNC, eds. Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989. Ventura SJ, Martin JA, Mathews TJ, Clarke SC. Advance report of final natality statistics, 1994. Month Vital Stat Rep 1996; 44 ( 1 1 snppl):15. Chalmers I ed. Oxford Database of Perinatal Trials. Oxford: Oxford University Press, 1988. Cochrane Collaboration. Cochrane Collaboration Pregnancy and Childbirth Database. Oxford: Update Software, 1995. James NT, Letter to the editor, BMJ 1996;313:169-170. Sackett DL, Rosenberg WMC, Muir Gray JA, et al. Evidence based medicine: What it is and what it isn’t. BMJ 1996;312: 11-12. Cochrane A. Effectiveness and Efficiency: Random Reflections on Health Services. Cambridge: Cambridge University Press, 1971. Grant JM. Multicentre trials in obstetrics and gynaecology (editorial). Br J Obstet Gynaecol 1996;103:599-601.